DECLARATION/DURABLE POWER OF ATTORNEY
WITH RESPECT TO HEALTH CARE DECISIONS
AND POST-MORTEM DECISIONS

FOR USE IN THE STATE OF LOUISIANA

I, _____________________________________, hereby declare as follows:

1. Appointment of Agent: In recognition of the fact that
there may come a time when I will become unable to make my own
health care decisions because of illness, injury or other
circumstances, I hereby appoint, under the laws governing
declarations concerning life-sustaining procedures, durable
powers of attorney, or any other applicable provision of law

as my health care agent/attorney-in-fact (referred to herein as
my "agent") to make any and all health care decisions for me,
consistent with my wishes as set forth in this directive, and
subject to any specific requirements and limitations of
applicable law.

If the person named above is unable, unwilling or unavailable to
act as my agent, I hereby appoint

This appointment shall take effect in the event I become unable, because
of illness, injury or other circumstances, to make my own health care
decisions.

2. Jewish Law to Govern Health Care Decisions: I am Jewish.
It is my desire, and I hereby direct, that all health care decisions
made for me be made pursuant to Jewish law and custom as determined
in accordance with strict Orthodox interpretation and tradition.
By way of example, and without limiting in any way the generality
of the foregoing, it is my wish that Jewish law and custom should
dictate the course of my health care with respect to such matters
as the performance or non-performance of cardio-pulmonary
resuscitation if I suffer cardiac or respiratory arrest; the
initiation or discontinuance of any particular course of medical
treatment or other form of life-support maintenance, including
tube-delivered nutrition and hydration; and the method and timing
of determination of death.

3. Ascertaining the Requirements of Jewish Law: In order to
effectuate my wishes, if any question arises as to the requirements of
Jewish law and custom in connection with this declaration, I direct my
agent to consult with and follow the guidance of the following Orthodox
Rabbi:

If such rabbi is unable, unwilling or unavailable to provide such
consultation and guidance, then I direct my agent to consult with and
follow the guidance of an Orthodox Rabbi referred by the following
Orthodox Jewish institution or organization:

If such institution or organization is unable, unwilling or unavailable
to make such a reference, or if the rabbi referred by such institution
or organization is unable, unwilling or unavailable to provide such
guidance, then I direct my agent to consult with and follow the guidance
of an Orthodox Rabbi whose guidance on issues of Jewish law and custom
my agent in good faith believes I would respect and follow.

4. Direction to Health Care Providers: Any health care provider
shall rely upon and carry out the decisions of my agent, and may assume
that such decisions reflect my wishes and were arrived at in accordance
with the procedures set forth in this directive, unless such health care
provider shall have good cause to believe that my agent has not acted
in good faith in accordance with my wishes as expressed in this directive.

If the persons designated in paragraph 1 above as my agent and alternate
agent are unable, unwilling or unavailable to serve in such capacity, it
is my desire, and I hereby direct, that any health care provider or other
person who will be making health care decisions on my behalf follow the
procedures outlined in paragraph 3 above if any questions of Jewish law
and custom should arise.

Pending contact with the agent and/or rabbi described above, it is my
desire, and I hereby direct, that all health care providers undertake
all essential emergency and/or life sustaining measures on my behalf.

5. Post-Mortem Decisions: It is also my desire, and I hereby
direct, that after my death, all decisions concerning the handling and
disposition of my body be made pursuant to Jewish law and custom as
determined in accordance with strict Orthodox interpretation and
tradition. By way of example, and without limiting in any way the
generality of the foregoing, it is my wish that there be conformance
with Jewish law and custom with respect to such matters and questions
as whether there exist exceptional circumstances that would permit an
exception to the general prohibition under Jewish law against the
performance of an autopsy or dissection of my body; the permissibility
or non-permissibility of the removal and usage of any of my body organs
or tissue for transplantation purposes; and the expeditious burial of
my body and all preparations leading to burial.

Time is of the essence with regard to these questions. I therefore
direct that any health care provider in attendance at my death notify
the agent and/or rabbi described above immediately upon my death, in
addition to any other person whose consent by law must be solicited and
obtained prior to the use of any part of my body as an anatomical gift,
so that appropriate decisions and arrangements can be made in accordance
with my wishes. Pending such notification, it is my desire, and I
hereby direct, that no autopsy, dissection or other post-mortem
procedure be performed on my body.

6. Incontrovertible Evidence of My Wishes: If, for any reason,
this document is deemed not legally effective as a declaration concerning
life-sustaining procedures and/or as a durable power of attorney for
health care, or if the persons designated in paragraph 1 above as my
agent and alternate agent are unable, unwilling or unavailable to serve
in such capacity, I declare to my family, my doctor and anyone else whom
it may concern that the wishes I have expressed herein with regard to
compliance with Jewish law and custom should be treated as
incontrovertible evidence of my intent and desire with respect to all
health care measures and post-mortem procedures; and that it is my wish
that the procedure outlined in paragraph 3 above should be followed if
any questions of Jewish law and custom should arise.

7. Severability: In the event that any provision of this directive
shall be held invalid or unenforceable, it shall not in any way invalidate,
affect, or impair the remaining provisions of this directive, it being my
intention that this directive shall be enforced to the extent permitted by
law.

8. Duration and Revocation: It is my understanding and intention
that unless I revoke this declaration/durable power of attorney, it will
remain in effect indefinitely. My signature on this document shall be
deemed to constitute a revocation of any prior health care declaration,
durable power of attorney or other similar document I may have executed
prior to today's date.

I understand the full import of this declaration and I am emotionally and
mentally competent to make this declaration.

SUBSCRIBED and sworn to before me by _____________________________________,
the declarant, and _____________________________ and ______________________________,
witnesses, as the voluntary act and deed of the declarant this _______
day of _____________, 199___.

__________________________________
Notary Public

SEAL

Note: The text of this document was prepared more than ten years ago. We therefore recommend you consult with a local estates and trusts attorney before executing this document to ensure that it conforms to current state law. Agudath Israel is in the process of updating the Halachic Living Wills for most states.